Retinal Detachments

Retinal detachments are rare, occurring at a rate of about 1 in 10,000 people per year. Until several years ago, detached retinas were a common source of blindness. Previous ocular surgery, injury, certain medical conditions and some genetic disorders can sometimes predispose a person to a retinal detachment, but often there is no preceding event or trigger.

A retinal detachment is caused when the vitreous gel inside the eye collapses creating tension on the retina resulting in a retinal tear. It is through this break or tear that fluid begins to accumulate underneath the retina. This progressive blister of fluid enlarges around the retinal break to extend more posteriorly and can involve the central retina, resulting in decreased vision. Once this blister of subretinal fluid becomes large enough, it is called a retinal detachment and side vision may be lost.

The natural course of retinal detachments is progressive and leads to complete blindness if left untreated. Retinal detachments never repair themselves, although some progress rapidly and others very slowly.

If caught at a very early stage of their development, some retinal detachments can be treated with laser photocoagulation or a freezing technique known as cryoretinopexy. At later stages of development, a gas injection may sometimes be chosen to repair selected retinal detachments. This gas injection is called pneumatic retinopexy and is combined with laser photocoagulation and/or cryoretinopexy applied at the same or a later date. As an in-office procedure, a gas bubble is injected into the eye and the patient is instructed on the proper head positioning to hold the gas bubble over the break and close the hole. As long as the hole is closed, sub-retinal fluid will absorb. When the retina is flat, laser photocoagulation or cryoretinopexy is used to permanently hold the retina in place. The single surgery success rate is lower (70-80%) than other techniques (i.e.,80-90% for a scleral buckle), but when successful, the final vision is often better than with other techniques. If it fails and other techniques are needed, there is no vision penalty-"no bridges have been burned." The gas bubble will absorb on its own in 1-3 weeks.

Many times, however, a scleral buckle procedure is required to repair the retinal detachment and may be the first choice of treatment for the detachment. This involves placing a belt of medical grade silicone plastic around the eye in the operating room. The indentation closes the break from outside the eye. Sometimes it is necessary to drain the sub-retinal fluid, and/or put some gas inside the eye, but these decisions are made at the time of surgery. Every effort is made to do all that is necessary to achieve retinal re-attachment. The goal of surgery is to close the break, reduce retinal traction, and then postoperatively allow some time to pass for the retina to become firmly attached to the outer layers in its normal position. Approximately 1 in 10 patients require an additional procedure following the initial procedure. Sometimes pars plana vitrectomy, with or without a scleral buckle, is needed, and is often the first choice in selected patients. This is a procedure where the vitreous is removed from inside the eye to relieve traction or to remove opacities that obscure the surgeon's view of the retinal tear that is the cause of the detachment. Overall, 95-98% of all retinal detachments can be successfully reattached, but 2-5% fail in spite of out best and sometimes multiple efforts. There is a great deal of research being done in the area of failed retinal detachments. Unfortunately, there is no 100% cure.

The final visual outcome is sometimes unpredictable pre-operatively. Even though a retinal detachment might be fully reattached and "successfully" repaired, the visual acuity may be less than what it had been before the detachment occurred. If the macula (the area of the retina that provides the most sensitive vision) is detached, it will continue to heal for several months after surgery, but still may be permanently damaged by the original detachment and limit the final vision recovery. If there is no improvement in straight ahead vision following successful retinal detachment surgery, the restoration or preservation of peripheral vision alone makes surgery worthwhile. Even if the visual acuity prior to retinal detachment surgery was not involved, the vision may be limited post-operatively for a number of reasons, including: fluid within the retina, cataract, membranes distorting the retina, and occasionally a hole in the macula. These possible complications can sometimes be treated with further surgery or medications.

Besides failure to reattach the retina and possible limited vision after surgery, other complications could include infection, migration or erosion of the plastic band, hemorrhage, cataract (or dislocated lens-if an implant is in place) and glaucoma. Most of these complications can generally be successfully dealt with, but not always. Potentially blindness or loss of an eye can occur. Fortunately, this is rare. Considering the natural course of the disease where there is 100% chance of blindness without surgery, these risks are acceptable, low, and should not dissuade you from surgery.

The scleral buckling surgery generally takes about an hour and is often done under general anesthesia, that is, with the patient fully asleep. Vitrectomy surgery may be done with general anesthesia also as an outpatient procedure. Both procedures may rarely require overnight hospitalization. It takes 2-4 weeks for the retina to maximally bond to its proper position. Most of this bonding, however, is complete within the first week. Limited activity or special positioning (link to "face-down postoperative positioning" article below) will be required for approximately 5-10 days following surgery. In particular, it will be necessary to reduce activities such as reading and driving where rapid eye movements could create new retinal traction and/or allow fluid to re-collect underneath the retina causing a re-detachment. Follow-up arrangements and instructions for postoperative care will be given at the time of your discharge.

If you have any additional questions, please feel free to discuss them with me at anytime.

David V. Poer, M.D., F.A.C.S.